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Introduction Spontaneous hemoperitoneum secondary to a follicular ovarian cyst rupture is a rare, but potentially life-threatening presentation. We present a case of a 17-year-old with massive hemoperitoneum from an ovarian cyst. She was diagnosed with pancytopenia which created a diagnostic challenge as the differentials varied from Vitamin B12 deficiency to bone marrow failure. Case A 17-year-old girl presented to us with a two-day history of left iliac fossa pain, associated with postural hypotension and easy bruising. Her urine pregnancy test was negative. A CT scan revealed hemoperitoneum. Hemodynamic stability was ensured with multidisciplinary involvement from hematologist and anesthetist. A laparoscopy confirmed a ruptured left ovarian follicular cyst with a liter of hemoperitoneum. Her hemoglobin was 5.5 g/dL, platelets 12,000/?L, and white cell count of 1,900/?L. Blood smear indicated macrocytes and polychromasia, with an MCV of 115 FL. Coagulation parameters were normal with no evidence of hemolysis. B12 deficiency was suspected with mildly reduced serum B12 levels. Folate levels were normal. She was started on parenteral B12 supplementation, and at discharge, her platelet count was 44,000/?L, white cell counts 4,000/?L, and hemoglobin 98 g/L after transfusions. However, at follow up, her counts remained persistently low, latest being Hb 7g/dl, platelets 9000/?L and white cell count of 2900/?L. She was supported with weekly transfusions and prophylactic antibiotics. Her viral markers and autoimmune markers were negative. A bone marrow biopsy revealed severe aplastic anemia with low level PNH clones. A diagnosis of bone marrow failure was made and she has been referred to a higher Centre for investigations and treatment. Discussion Aplastic anemia causes pancytopenia due to bone marrow failure. More than 70% of cases are considered idiopathic. The signs and symptoms can be very subtle and difficult to diagnose. This diagnosis requires exclusion of other congenital or acquired marrow failure syndromes, such as Fanconi anemia, dyskeratosis congenita, and paroxysmal nocturnal hemoglobinuria. Hence the diagnosis requires close collaboration with hematology specialists. In this case, she had signs of easy bruising and fatigue for many weeks before the presentation, which went undiagnosed. Secondly, the mildly reduced vitamin B12 levels acted as a confounding factor in delaying the real diagnosis.